To exist: from the Latin existere, to stand forth, or to take a stand.

For more than a century, the mass media have influenced body image, gender identity, and eating. Today we are inundated with instant communications, 24-hour programming, digital blurring of fantasy, reality, and possibility, and sophisticated, targeted marketing.

Mass media are in some ways a direct reflection of modern life: off-putting andseductive, magical and mundane, complex and stupefyingly simple, exciting and stultifying, and everywhere, yet all too often seemingly nowhere.

Could such a cultural institution cause eating disorders? Some people, including many professionals, find the answer of yes to this question to be understated, if not insultingly obvious. Yet other people find the question itself to be insulting. Today, many clinicians and families advocate the position that eating disorders are chronic biopsychiatric disorders with a genetic basis and neurochemical manifestations, and that, consequently, sociocultural factors play a much smaller and decidedly nebulous role.

Setting a productive course through these conflicting currents requires patience and attention to detail. Based on my 16 years of studying and writing literature reviews, including meta-analyses, there is little doubt that mass media contributes to risk factors that in turn increase the probability of the spectrum of disordered eating. Make no mistake: there have indeed been many exciting, promising, and potentially significant developments in the biopsychology and biopsychiatry of eating disorders. Nevertheless, it is important for clinicians, and especially those who staunchly defend a scientist-practitioner perspective, not to ignore the mountain(s) of empirical evidence highlighting the role of mass media in creating the conditions that enable eating disorders to arise as a public health concern. In fact, as Linda Smolak and I have maintained for some time now, there is much more evidence that sociocultural factors play a role as variable, causal risk factors for the spectrum of disordered eating and related conditions (e.g., depression and obesity in adolescent girls) than there is evidence of genetic causes (vs. correlates) of eating disorders. Moreover, the prominence of mass media and other sociocultural factors in the development and maintenance of disordered eating has a number of practical implications for various aspects of clinical work, ranging from prevention to assessment, treatment, public education, and advocacy.

I sometimes ask audience members what the nervosa in anorexia nervosa and bulimia nervosa means. Typically the response is nervous (no pun intended) silence and perplexity. Some reply that it means a connection to the nerves, indicating that the origin of these conditions is to be found in the central nervous system. I then inquire whether conditions like Tourettes or Parkinsons should therefore include nervosa as part of their label. After a bit, people realize or concede that nervosa pertains to some underlying psychopathology, as seen in anxieties, sensitivities, and unhealthy coping mechanisms that themselves are the hallmarks of what was once known as neurosis.

Of course, there is ongoing disagreement about the foundations of that nervosa. Nevertheless, many experts would admit that it typically has components of irrationally high ideals, self-loathing, an externally defined sense of self, drive for thinness, fear of fat, negative body image(s), fears and fantasies about food, concerns about the ambiguities of sexual maturation in a culture that objectifies women, and so forth. Then, I ask: If you set out to create a society with the conditions in which these components would flourishand occasionally combine to form relatively rare (2-4% point prevalence post-puberty)what would you need to control? The schoolsthat is, the site of many of our best prevention efforts? Many answer, No, the mass media. In summary, the components that together form the foundation for anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified are extremely prevalent in our society. Its hard to understand how these could be that prevalent, that well entrenched, and so resistant to change without mass media playing a key role.

The obsession with the morality of fat (bad, ugly, irresponsible) versus thin (good, beautiful, and in control) has also gained a foothold in our culture. In 2000, Dr. Mimi Nichter, a medical anthropologist at the University of Arizona, published a book, Fat Talk (Harvard University Press), which provided an ethnography of middle school and high school girls communication around the subject of fat. One of the most striking findings was that nearly all the girls interviewed were fluent in speaking and understanding the language of feeling fat, and that this linguistic tool for expressing distress and seeking and maintaining connection crossed all cliques, as well as economic and sociocultural lines. Once again, it is hard to imagine how our culture would be organized in such clear, strong, and expansive lines without the impact of a mass media that so clearly teaches the morality of fat and thin while fusing femininity, body, fat, and self-management in order to impress and please others.

Some argue that the impact of mass media cannot be so great because, after all, millions of young women are exposed to media messages every day, yet only a small number develop an eating disorder. This argument sounds like a truism, but it is a shallow one that in no way negates the power of mass media. With a rare disorder like schizophrenia or bipolar disorder or bulimia nervosa, four prevalent and relatively independent risk factors could combine multiplicatively (e.g., .404) to explain an overall low risk in a population (~.026). In this way, various combinations of sociocultural and biopsychological risk factorsfor example, people exposed to and engaged in the mass media, pressures at home, fat talk or from peers, and who have a genetic predisposition to an anxiety disorder (or have been sexually abused)can increase the risk of a relatively rare and multiply determined condition such as an eating disorder.

What Does This Mean to Clinicians?

One immediate implication is that it is very important for clinicians to think carefully and critically about the nature, strengths, and drawbacks of mass media, just as it is important to understand the role of culture, ethnicity, gender, and sexual orientation in the development of disorders that affect so many more girls and women than boys and men. As is the case for clinicians working with people who have substance abuse or dependence problems, at various points in the process of assessment, treatment planning, treatment, and support for eating disorders, clinicians need to engage in truth-telling about the toxic nature of certain environmentsand to model (embody) and talk about the skills and attitudes necessary to resist and transform those messages. Note that a critical understanding of media is simultaneously appreciative, suspicious, hopeful, and practical; it is neither cynical nor disdainful. Ultimately, clients will need to forgive themselves and others for participation in the culture(s) of thin-ideal media, just as they need to grieve for what was lost in the pursuit of thinness or body image. And clients will need new role models (instead of fashion models) for the process of accepting what was while building resistance, assertion, and a commitment to change.

Media Literacy and Advocacy

Media literacy and cultural literacy are an important part of resisting and reversing toxic pressures. One important component of media literacy is developing and practicing the skills, knowledge and perspective to carefully and critically analyze messages in print, audio and video media. Another component is learning how to use mass media to assert ones commitment to a life and a society with different, healthier norms, values, and practices concerning body weight and shape, eating, activity, and so forth.

The first part of the work is encouraging people to make choices that make a difference. The challenge is to help clients be able to admit that the pressures to be thin, for example, are powerful, and to be able to resist buying into an incorrect message, just as it was once accepted that girls cannot play varsity sports. Washington State University communications professor Dr. Erica Austin offers an excellent metaphor for establishing the foundation of media literacy. She notes that the mass media are a very important and powerful set of tools for constructing and maintaining an educated democracy and yet, like all powerful tools, they require safety glasses. Cultural and media literacy can be thought of as safety glasses that help us to use media tools more productively and in more interesting ways, while helping us to see what needs to be challenged and what needs to be changed so we can make healthier choices. This sort of challenge (stop, evaluate, decide, take a stand) is an important step for making health more making health more attractive than illness.

The next step is using creative and well-planned approaches to translate the knowledge and feelings gained from a critical awareness (This is just wrong! We need to do something about this) into activism against offensive media and into advocacy of healthier messages by using mass media. As Dr. Niva Piran and I have written, media literacy contributes to the chances boys and girls have to build a new and healthier culture in their families and in the culture surrounding them.

Thus, three important components of media literacy for prevention of disordered eating appear to be: (1) critical evaluation of the media, (2) actively producing healthier media presentations, and (3) working to reduce appearance-based and focused social comparisons. The ingredients for developing and consolidating these components are, not surprisingly, the 5 Cs of prevention: Consciousness-raising;, building interpersonal Connections;, teaching Competencies;, and fostering Choice and Change. A good example of these features is found in the work of Oregon Health Science University researchers Linn Goldberg and Diane Elliot, whose ATLAS (Athletes Training and Learning to Avoid Steroids) and ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternatives) programs use these principles in programs for male and female athletes, respectively, to improve attitudes and behaviors in regard to weight, shape, strength, fitness, and health (Arch Pediatr Adolesc Med 2004; 58:1043 and J Sch Health; 2006;76:67).

How Clinicians Can Be Literacy Advocates

As scientist-practitioners, and as concerned citizens, clinicians need to make a commitment to challenging, publicly and professionally, the harmful aspects perpetuated by mass media. Clinicians need to follow the lead of Margo Maine, Susie Orbach, Carolyn Becker, Anne Kearney-Cooke, Beth McGilley, Catherine Steiner-Adair, and others who take a stand (and a stance) by proactively expressing and asserting themselves to and through the media itself. How can we do this? We can guide and empower individual clients or groups to speak up for themselves; we can speak to schools and school boards, policy makers in local and federal government, and we can speak to and educate and guide professionals and volunteers who are engaged in public awareness, treatment and prevention. Each of us can make a difference in our own practices by helping clients see the craziness of the negative body messages we all receive each day and by helping them and ourselves be courageous toward the hazards of glorification of thinness and social comparisons.

Courage, like clinical work itself, is often a tricky blend of anxiety, doubt, commitment, action, patience, and recommitment. Courage, clinical work, and media literacy all require a good deal of truth-telling. Clinicians, in fact, put themselves in the position of helping people in distress, including young people out of control who are really suffering, to begin to tell the truth about themselves, their families, and our current culture. Given the overwhelming evidence pointing to the impact of mass media and other prominent aspects of culture, critical evaluation and truth-telling about these sociocultural factors needs to be a part of the effort to help clientsand those at risk around themsee that at any point it is possible and admirable to take a stand, stand out, and choose a healthier direction for the future.